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Tag Archives: secondary trauma

Nurses and other health professionals are expected to attend to hand hygiene about eleventy seven times a day. The WHO and HHA recommend 5 moments for hand hygiene: before touching a patient, before clean/aseptic procedures, after body fluid exposure/risk, after touching a patient, and after touching patient surroundings. 57.4% of Australia’s nurses/midwives are hospital/ward-based [source], they’re doing A LOT of hand hygiene.

On top of that, while they’re going about their business and busyness, ward-based nurses are interrupted10 times an hour [source]. Yep, every 6 minutes there’s something or somebody distracting us from our tasks and thoughts. Dangerously disorderly much? Hopefully that doesn’t happen to neurosurgeons, commercial airline pilots, tattoo artists or Batman.
Especially Batman.

Pro-Tip: most of us can not do this at work. Only respond to distractions with face-slapping if you are Batman.

So, here’s the idea: if you’re going to do hand hygiene dozens of times a day anyway, don’t just do it for your patients: do it for yourself too. We’re not cold callous reptilian clinicians, we’re educated warm-blooded mammals who do emotional labour. We need to nurture ourselves if we are to safely continue to nurture others.

Feel the product texture and temperature. The rub is cooler than the air. The rub is cooler than my fingers. It feels nice.

Start with cleaning. The first half of my hand hygiene routine is about rubbing stuff off. Let the stuff I want to get rid of float away.

Move on to restoration, healing. The second half of my hand hygiene routine is about rubbing in resilience and health. Let the stuff that sustains me seep into my skin.

Check in on the breathing. The slower and deeper the better. If the breathing or the brain are running too fast, slow down and repeat steps 5 and 6.

There’s no rush. Slowly scan the surroundings. With any luck someone from infection control is watching.

Smile.

Breathing slowly, its time let the air rinse off the residue.

One more slow breath. Its time to get back to work.

Mindful Minute (The 60-Second Handwash Version)

Step towards the sink with intent. This is my mindful minute. I’m taking a brief break.

Let the water flow.

Feel the water flowing over both hands. The water’s warmer than the air. The water’s warmer than my fingers. It feels nice.

Add soap. It’s slippery. Frictionless fingers feel fine.

Start with cleaning. The first half of your hand hygiene routine is about washing stuff away. Let the stuff you need to get rid of flow down the drain. Let it flow away.

Move on to restoration, healing. The second half of my hand hygiene routine is about rubbing in resilience and health. Let the stuff that sustains me seep into my skin.

Check in on the breathing. The slower and deeper the better. If the breathing or the brain are running too fast, slow down and repeat steps 5 and 6.

There’s no rush. Slowly scan the surroundings. With any luck someone from infection control is watching.

Smile.

Breathing slowly, its time rinse both hands.

Breathing slowly, its time to thoroughly dry both hands together.

Throw the towel in the bin.

One more slow breath. Its time to get back to work.

Clean hands save lives. Clear heads save lives too!

Acknowledgements & Context

This is not my original idea. I first stumbled across the idea of combining hand hygiene with head hygiene via Ian Miller‘s November 2013 blog post “mindfulness during handwashing”: http://thenursepath.com/2013/11/18/mindfulnurse-day-8/. I’ve been using the idea myself and suggesting it to colleagues and students ever since. When I left the clinical environment for a few months, I found myself really missing intentionally punctuating my day with mindful moments. Since returning to clinical practice I’ve come to appreciate the strategy even more than I did when I first started using it 3 years ago.

So why am I blogging about it too? Why now? Well, on Monday I attended the Australasian College for Infection Prevention and Control 2016 conference to chat about Twitter [link to that presentation here. Also, check-out the #ACIPC16 hashtag here and here]. Luckily I was there for the opening plenary sessions, and was pleasantly surprised at the emotional/psychological literacy that was being displayed and advocated for. The opening presentations by Peter Collignon, Mary Dixon Woods and Didier Pittet all went to some lengths to emphasise the importance of emotional intelligence, constructive communication and building relationships. It was really impressive stuff; giving the hand hygiene and mindful moments idea a remix is my way to give recognition/thanks to the #ACIPC16 conference delegates and organisers.

Suicide is a complex matter that does not lend itself to easy understanding or simple solutions. However, something we know about health professionals is that they know that there are mental health services and supports. Health professionals know that these services can be accessed by people who who are feeling suicidal. The data suggests that health professionals have an actual or perceived barrier to accessing these existing supports. I wonder what that barrier is.

Stigma?

Could it be that nurses, midwives and medical professionals suicide at a greater rate than the other occupations because of actual or perceived stigma? We have the peculiar privilege of providing care for strangers who are/have been suicidal, but perhaps we aren’t so good at extending that nurturing care to ourselves and each other.

I have a suggestion for health professionals. If you ever come across a colleague who says something derogatory or stigmatising about a person experiencing mental health problems or suicidality, politely show them the data,. Save the chart above to your phone and show them that suicide is a bigger problem for nurses, midwives and female medical professionals than it is for people in other occupations. Say something like, “Suicide is an important issue for our colleagues too. Let’s both care for this patient like we would like to be cared for.”

You’re very welcome to share the chart above or this blog post with your colleagues – the short URL is https://meta4RN.com/stigma

Hopefully, sometime down the track, the data will result in targeted support for the prevention of suicide by health professionals. However, we need not wait for our political masters, health bureaucracies and professional organisations before we walk-the-walk and talk-the-talk of fighting stigma.

If we see mental health/suicide stigma we should address it on the spot.

In the words of Lieutenant General David Morrison, “The standard you walk past, is the standard you accept.” As the data shows, it is dangerous for nurses, midwives, medical professionals and other health professionals to accept stigma.

Support

It’s important to acknowledge that talking and thinking about suicide can be distressing. People in Australia can access support via:

People have life threatening injuries and illnesses. People experience suicidal ideation and sometimes act on those thoughts. People experience delirium, dementia and psychosis – they lose touch with reality. People behave in unexpected and challenging ways.

All of these people are in crisis. They are having the worst day(s) of their life.

When you are part of the clinical team trying to help out these people it’s always useful to acknowledge and clarify the nature of the person’s crisis. It’s surprising what the individual’s perception of the crisis is. I’ve met a person who was desperately unwell – ICU unwell – who’s subjective crisis was that the cat was home alone without anyone to feed it. That was the crisis she wanted me to respond to. I’ve met quite a few people who need urgent medical/surgical interventions, but who perceive their biggest crisis as being unable to smoke a cigarette right now. I’ve had the peculiar privilege of spending time with people who have survived suicide attempts, who have experienced a crisis related to abuse, financial problems, relationship breakdown, and loss of job/role/independence/sense-of-self. An existential crisis in mind, body and spirit.

All of these people are in crisis. It is their crisis.

It is important to ascribe ownership. The nurse/midwife/physician/other clinician is not experiencing the crisis; they are responding to the crisis. We (the clinicians) have not been immunised against crises, but we do have the responsibility to do whatever we can to not get overwhelmed by them. Also, truth of the matter is, I’m not sure how long you would last if you responded to every day at work as an adrenaline-filled, too-busy-to-wee, emotional rollercoaster. That be the road to burnout and breakdown, my friend.

So, what do we do?

We use Jedi Mind Tricks, pithy sayings and clinical supervision. That’s what we do.

Clinical Supervision
I’ve written about clinical supervision before (here and here). Despite the name, it’s not about scrutiny. Clinical supervision is about reflecting on clinical practice with a trusted colleague, and asking simple questions of yourself: what did I do?; what were the outcomes?; how did I feel?; what lessons did I learn?.

The idea of clinical supervision is to acquire and refine clinical skills.

Pithy Sayings
A lot of us use and repeat pithy sayings such as the ED adage: “In the event of a cardiac arrest [or any other patient crisis for that matter], the first pulse you should take is your own.”

If you recognise your own anxiety you’re more capable of managing it. Intentional slow breathing is an excellent intervention for this. You can do it while you’re scanning the patient/file/environment.

Breath. Slowly.

It is not a crisis. A crisis is when there’s a fire, storm-surge, tsunami, earthquake or explosion that requires evacuation of staff and patients. If the hospital is not being evacuatedit’s not a crisis. It’s just another day at work.

Jedi Mind Tricks
The other thing I like to do when feeling anxious is impersonate a calm person. It’s like a Jedi mind trick. “This not the anxious nurse you’re looking for. This is a calm nurse.”

When impersonating a calm person I conjure-up a person who was a CNC when I was a student nurse at the Royal Adelaide Hospital. Part of the apprenticeship model of nursing education at the time was to give students experience in RN roles. I had been thrown into the Team Leader role on a day when the neuro ward was especially busy. There were emergency admissions, a stack of post-op patients – two of whom were really unwell, a person dying in the side room, and an inexperienced unqualified overwhelmed drongo (me) coordinating the whole thing. We were in trouble. We needed more nurses and a proper team leader.

I sought-out the CNC – a smart-as-a-whip young woman not much older than me (i was quite youngish 25 years ago). The CNC spent all of about 5 minutes with me prioritising the ward’s workflow:

“First things first. No need to shower/clean anyone unless they’re incontinent.” There goes about 50% of the morning’s workload in an instant.

“Don’t bother with routine 4-hourly obs unless the person looks unwell. Only the post-op patients and the clinically unwell patients need their obs done.” There goes another 10% of the work.

“Let’s get Fiona (the most experienced and skilled nurse on the shift) to look after the two dodgy post-op patients and nobody else.” The biggest concern was instantly taken care of.

“Bring all the nurses in here (a cramped nurses station overlooking 2 bays of 6 patients each) and tell them the plan. Make sure they all drink water and coordinate their breaks.” Got it. To look after the patients you need to look after the nurses.

We, nurses and patients alike, had a good shift. All the vital stuff was done. It wasn’t a crisis. It was a day at work.

I haven’t seen that CNC (her name is Lee Madden) since 1992, but I think of her every now and then. Whenever I see a crisis unfolding or see/feel anxiety rising, I wonder, “What would a calm person do?” and conjure an image of Lee floating serenely into the space. I channel Lee’s reassuring smile and clear understanding of priorities, and do my best to behave in the way she modelled to an impressionable overwhelmed student nurse.

Brianna Scully is a first year journalism student at the University of Technology Sydney. As well as writing stories for university, Brianna is also a Beauty Editorial Intern at Her Fashion Box. Although she hasn’t been studying journalism for long, Brianna is sure this is the right career path for her and wishes to work in print or television production in the future. @brianna_scully

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Will GP copayment increase violence in hospitals?

Although fire extinguishers are typically thought of as potentially life-saving devices, they proved the opposite to Paul McNamara when one was “being held at shoulder height by a tall, fit, powerful young man on a violent rampage in a medical ward.” This is the chilling account of mental health nurse Paul McNamara in his blog titled Emotional Aftershocks. Paul, who works in the medical and surgical wards of a large regional hospital, is one example of increasing violence against nurses in Australia.

A 2013 survey by Nursing Careers Allied Health revealed 39 per cent of nurses had experienced violence in the past five years. With massive cuts to health in this year’s Federal Budget, medical professionals and experts predict that violence against nurses in hospitals will rise.

A spokesperson for the Victorian Branch of the Australian Nurses and Midwifery Federation said violence has increased due to “an increase in methamphetamine abuse by the public, staffing shortages in hospitals and longer waiting periods in emergency departments.” Michael Roche, senior health lecturer and coordinator of the Glueing it Together: Nurses, their work environment and patient safety study in NSW, believes adequate staffing is key in preventing violence, and that budget cuts to health will have a detrimental outcome. “We have found that a higher proportion of registered nurses was associated with lower rates of violence, so a corresponding reduction would likely increase rates. . .if fewer staff were available then it is easy to see how patients and families could become frustrated, increasing the potential for violence.”

Paul McNamara believes violence against nurses was not as much of an issue for previous generations. “Intoxication with alcohol and amphetamines is certainly part of the problem, but there’s more to it I think; something to do with a change in culture perhaps.”

Tara Nipe, a nurse at a tertiary metropolitan hospital, believes the proposed $7 co-payment for visits to the GP will prevent early detection of illnesses and lead to increasing numbers of patients needing emergency care. “If it’s a choice between a $7 GP fee or bread, milk, cereal and spreads for a week, some people will decide not to go in about that red, sore patch on their leg, pain in urination, or really nasty cold . . . When they present to emergency departments they’ll be sicker, needing admission and expensive intervention, putting more pressure on an already stretched system, and increasing the kinds of factors that contribute to violence.”

According to an ABC article, Health Minister Peter Dutton claimed co-payments would be beneficial to those who can’t afford healthcare in the future. However, the NSW Shadow Minister for Health Andrew McDonald believes the co-payment is a “dreadful policy” that will be “extremely damaging to the Australian health system.” Dr. McDonald believes the most effective way to prevent violence is to abandon the co-payment. “It [violence] certainly is a problem that is increasing and one that will certainly get worse if our emergency departments go into meltdown, as is highly likely with co-payments.”

Despite the fact he was not physically harmed, Paul McNamara suffered emotionally after the event, writing: “[I] get teary every now and then when I think of what could have happened: those skull-cracking thoughts are the worst bit.” Although there are calls for a ‘Zero Tolerance Policy’ where no act of violence is tolerated by medical staff, Paul believes a caring approach is more effective. “Not every nurse gets exposed to violence or abuse, but you’ll see it up-close-and-personal through your patient’s eyes sometimes. Nurses do emotional labour: be prepared for the emotional aftershocks that come with the job.”

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End

Many thanks to Briana Scully for contributing this article, initially written as an assignment for her journalism course, to be the inaugural guest post on meta4RN.com. In keeping with an university assignment Briana listed her sources, but they have not been included on the online version. To contact Briana directly go via Twitter: @brianna_scully

As always, please feel free to leave comments below. I would be pleased to hear from others interested in contributing a guest post to meta4RN.com (especially, but not limited to, students who have an assignment that it is likely to be of interest to nurses and midwives).

The Adelaide Crows, like all elite sporting teams, spend a lot of time preparing to play. For those unfamiliar with Australian Rules Football (AFL) it’s a fast, free-flowing, physical game that is played weekly during the winter months. Here’s a sample of play:

A game of AFL is played over four quarters, each lasting approximately 30 minutes (nominally each quarter is 20 minutes, but the clock stops when the ball is out of play). So, any player who stays on the ground for every moment of the game will play for two hours.

Think about what goes into preparation: recovery from the previous game, keeping-up and improving fitness levels, practicing individual skills, practicing team skills, discussing and developing team strategies, having coaches give feedback on what you did well and what areas could be improved, developing on-ground leadership and communication skills, nurturing confidence in yourself and your team-mates, learning about the team you’ll be playing against next week. The list goes on.

My brother, Bernie McNamara, has seen the Adelaide Crows up-close and personal over the last few years. Bern says that typically during the season a player will have about 25 contact hours each week with the club, and be expected to do about 10 hours of preparation away from the club.

So, each week, a diligent AFL player will spend about 35 hours preparing for no more than 2 hours play.

How does that preparation:work ratio compare for clinicians?

It’s not just the explicit hands-on knowledge that counts, it’s also very important that we make time for thinking-about, discussing and reflecting on our clinical roles. Clinicians, like footballers, have a desire to improve, but we may have to fight for support to do so. As noted at a recent seminar regarding clinical supervision, “in a time of austerity, high caseloads and increasing problems, the organisation is often satisfied with a ‘good enough’ (work task) rather than seeking excellence. This tends to reduce supervision to a control function rather than aspiring to best practice.” Source: Talking about supervision: conversations in Bolzano and London

I have written about clinical supervision previously (in “Nurturing the Nurturers” meta4RN.com/nurturers), but perhaps undersold it – some have commented that it seems like a feel-good exercise for clinicians. There’s more to it than that.

Clinical supervision is a key component in providing high quality services with positive outcomes for those who use health services. Clinical supervision promotes a well trained, highly skilled and supported workforce, and adds to the development, retention and motivation of the workforce. High quality clinical supervision also contributes to meeting performance standards, meeting the expectations of consumers/carers/families and goes a long way towards developing a learning culture in a changing health care environment. Source: ClinicalSupervision

Clinical supervision guidelines are very modest compared to the preparation:work ratio of AFL footballers. Clinical supervision requires nothing like the investment of 35 hours of preparation for 2 hours of play, instead, it’s something like 1 hour of preparation for every 80 or 160 hours of work.

Warning: today I will take the risk of being ridiculed for over-sharing and being melodramatic (it’s a grand tradition amongst bloggers).

Crap Day at Work

Recently at work I spent a bit of time wondering whether I, one of my nursing colleagues, or one of the hospital patients or visitors was going to sustain a life-threatening brain injury at the hands of a man brandishing a fire extinguisher as if it were a weapon. Fire extinguishers are generally thought of as potentially life-saving devices. However, when a fire extinguisher is being held at shoulder height by a tall, fit, powerful young man on a violent rampage in a medical ward they don’t look like life-savers.

Fire extinguishers weigh 9kg and are made of steel. The fire extinguisher this man was holding looked a lot like a skull-cracking device to me. It was the most frightening workplace incident I have experienced.

I have been a nurse for 25 years. Like many nurses I have been struck while at work (39% of nurses have experienced physical violence according to this recent Australian survey, 36% worldwide says this quantitative review). I am lucky: I have only been hit by frail people with delirium or dementia, so have never been hurt – just surprised and amused. To illustrate: once, an elderly lady forgot I was the nurse making her bed, and suddenly started punching me (with the strength of a wet kitten) saying, “Stop it Malcolm! Don’t take my money from under the mattress and go to the pub again! You’re such a bastard Malcolm!” It was pretty funny – always wondered whether Malcolm was a memory from her past or a distortion of the present (probably a bit of both).

Zero Tolerance is Unrealistic and Unfair

I am not a fan of being abused or hit, but think that the “Zero Tolerance” campaigns that have popped-up in health services in Australia over the last 5-10 years are unrealistic and unfair.

This shouty “ZERO TOLERANCE NO EXCUSE FOR ABUSE” poster hangs in the main corridor of a medical ward, adjacent to the nurses station.

Unrealistic because it is inevitable that health services, hospitals especially, will have a large percentage of patients who have cognitive and perceptual deficits due to the very medical condition that has them bought them to the health facility in the first place. More than half of older persons admitted to hospital will experience delirium, and about 9% of the over-65s (a significant component of health service users) have dementia. Often these people will not have the cognitive capacity to discriminate between friend and foe, and will, at times, lash out to defend themselves against a perceived threat. We can look out for the warning signs and be proactive in protecting ourselves, but we can not expect to transfer responsibility for our safety onto someone who does not have the cognitive capacity to even keep themselves safe.

In the health system it is very common to be spending time with people who are having the most traumatic, frightening and disempowering day(s) of their life. It would be lovely for staff if everyone experiencing acute emotional distress expressed their emotions in a clear, calm and composed manner, but is it realistic?

The “zero tolerance” concept is unfair because it is not reciprocated. We (that’s “we” as in “we the health system”) require patients and their loved-ones to be incredibly tolerant of us. Think waiting lists, physical discomfort, unplanned delays, unclear communication, unmet expectations, cancelled procedures, lack of privacy, lack of dignity, lack of control, lack of compassion, lack of progress… the list could go on. Can you find me a health facility where no patient has ever experienced these things? Our health system relies on people being tolerant – this “zero tolerance” malarkey doesn’t allow for a bit of crap.

Instead of zero tolerance, it is more realistic to expect that patients will occasionally need to vent their emotions. Not just the pleasant emotions like love, joy, gratitude and kindness, but also the less comfortable human emotions like grief, anger, sadness, worry, despair, frustration, fear, pain and hate. For these emotions swear words are adjectives, a raised voice is empowering, tears are cathartic.

In “Nursing Ring Theory” (more info here: impactednurse.com) when someone is in a ring that is smaller than the ring you are in you offer support, compassion, care and skilful expertise. When someone is in a ring that is larger than yours you are allowed to ventilate your emotions with them. It is pure client centred care: everyone sends care going towards the direction of the patient and accepts that there will be crap coming out at times.

This acknowledgement of crap coming out is not an offer to hold out nurses and other health care workers as targets for abuse. That’s not OK. However, let’s shelf the zero tolerance crap: of course we’re tolerant of people ventilating their emotions. All we ask is that nobody is put at risk and those closest to direct patient care also have an avenue to safely ventilate their crap.

In ring theory care goes towards the patient and crap moves away from the patient. Proximity to the centre of the ring will be a fair predictor of the intensity of both care and crap.

Fire Extinguisher Guy*

Fire extinguisher guy is admitted to a medical ward for investigation of possible neurological disorder, but it might be something mental health related. So the Consultation Liaison CNC (me) spent a lot of time talking to fire extinguisher guy before the violent outburst, and again afterwards.

Fire extinguisher guy works hard, is creative, can be warm and funny at times; sadness, anger and tears bubble-up during our conversation then settle quickly. Talking to someone is both distressing and helpful, says fire extinguisher guy. He wants to get these strong, bouncing-all-over-the-place emotions under better control. Fire extinguisher guy’s experience of terrible abuse in childhood and his recent over-the-top cannabis and alcohol use wouldn’t be helping his labile hypomanic symptoms.

Fire extinguisher guy isn’t an unlikable person – he has a job, a car, a girlfriend, workmates, footy mates, other friends and a family. Fire extinguisher guy and the people who love him are all normal people. Fire extinguisher guy is one of the 20% of Australians who will experience problems with their mental health this year.

I am really grateful that fire extinguisher guy made the choice to direct his violence at property and not people. He had the capacity to make a very bad decision to hurt somebody; he chose not to. The only person physically harmed during this violent outburst was fire extinguisher guy himself: cuts from punching glass, bruises from punching and kicking windows, doors and walls of the medical ward.

I can’t figure out how long fire extinguisher guy’s violent outburst lasted. Replaying the scene in my mind I guess it was less than 2 minutes, but it’s like time measured in dog years… even though everything happened very quickly it somehow felt like slow motion too.

The fire extinguisher had been hurled into a storeroom doorway (THUD! CRACK!), the outburst was tentatively over, and fire extinguisher guy’s mum and i were lightly holding him and talking to him quietly when security arrived. Fire extinguisher guy allowed us to lead to him to an empty room and was cooperative with all of our suggestions and interventions. He apologised first to me, then to each of the other clinicians who provided care in those first couple of hours after the event. His apologies were heartfelt. He let the nurses, the doctor and the cleaner go about their business uninterrupted: his wounds were dressed, he accepted oral medications to dampen the intensity of his emotions, the blood and broken glass were cleaned-up, the other patients and visitors were reassured, detailed file entries were made, incident reports were filled-in, and negotiations between various members of the hospital’s multidisciplinary team were underway. The request for transfer off the medical ward could not be accommodated, but the insistence on two security guards overnight for staff and patient safety was.

Those of us up-close-and-personal to the incident took a couple of moments to exchange thoughts, but we tried not to get too bogged down in feelings at the time – it’s the beginning of the shift and fire extinguisher guy is just one of many patients on this busy medical ward.

Hole punched in the wall? No problem! One of the nurses covered the hole with this poster. Nurses are good at irony.

There is a hole in the wall that fire extinguisher guy created by punching it. One of the senior nurses on the medical ward covers the hole in with an anti-violence poster. We all laugh at the delicious irony and get on with our jobs.

As with the poster covering the hole, we crudely paper-over the cracks… it’s not fixing a problem, just covering it over… that’s good enough for now.

Emotional Aftershocks

In the days that follow I find myself a bit preoccupied at times thinking about the event. Get teary every now and then when I think of what could have happened: those skull-cracking thoughts are the worst bit… acquired brain injury anyone?

Skull-cracking thoughts are from my fear and imagination not from what actually happened.

That’s a good reminder. Keep saying that.

I’m OK: no flashbacks, no vivid dreams, no avoidance, no hyperarousal. I was back at work the next day (left a few hours early because I stayed back a few hours with fire extinguisher guy the night before). I’m seeing patients in the same medical and surgical wards, spending time with my very supportive colleagues.

I’m OK: I’m resisting the urge to quietly whisper to every fire extinguisher in the hospital, “Stay where you are my little red friend. Stay gently hooked on the wall. Do not allow yourself to be raised higher than my head. Please don’t go violently leaping about medical wards – people don’t like that THUD! CRACK! sound you make. Stay exactly where you are my little red friend.”

I’m OK: I’ve told the story a few times now – it’s losing its potency. The funny bit about the poster is good – every story needs a punchline (you’re welcome). The scary bit about the fire extinguisher is getting less vivid – it feels more like a story from the past now. It’s turning into a half-joke about fire extinguishers staying on walls exactly where they belong.

I’m OK: the only thing I’ve noticed is a bit of kummerspeck (great word, eh?). Kummerspeck is a German word that literally translates as “grief-bacon” – it refers to the weight gained through emotional over-eating. I’ve had to let my belt out a notch, and my favourite shirt feels too tight. Still going to the gym, so it must be the eating, Better keep an eye on that.

Yeah yeah yeah. If you’re so OK why are you blogging about it?

Part of the motivation is catharsis. Very self-indulgent, I know.

More importantly, senior clinicians should offer information and support that will empower and protect junior clinicians. Just a few days after the most frightening workplace incident I have experienced these two tweets popped-up on Twitter:

I do not know either of these people IRL (In Real Life), but I do feel a tremendous responsibility towards Emily, Dani and any other nearly-nurse who is as enthusiastic and passionate as these two. But what to say to Emily and Dani? How do we nurture them safely into our profession and keep their enthusiasm intact?

Referring to a patient as “fire extinguisher guy” is not a good example to set (more about that later – look for the red asterisk*).

As a senior nurse I should be supportive and encouraging to Dani, Emily and other enthusiastic nearly-nurses, and also be providing safety-tips and useful hints. I have two:

One: Make Like a Boy Scout

Be prepared.

Be prepared for some fantastic days at work where you’ll glide home feeling like you’re doing the most important and rewarding work that any one human can do. Those will be the days where you will use your knowledge-base, your skill-set and (most importantly) yourself to make a profoundly positive difference in somebody’s life. That person might never forget you.

Not every nurse gets exposed to violence or abuse, but you’ll see it up-close-and-personal through your patient’s eyes sometimes. Nurses do emotional labour: be prepared for the emotional aftershocks that come with the job. Find out about stress reactions and how to be pro-active in protecting yourself. I have an old, kind-of-dicky resource to share with you here, but you might find something better.

I am so angry that my nurse and midwife colleagues don’t have ready access to clinical supervision as a tool to reflect on practice and keep themselves (and their patients) safe. People say it would be too expensive to provide clinical supervision to every nurse who wants it, but there is huge cost already being paid. This cost (in terms of relationship stress, sleep disturbance, emotional trauma, anxiety, depression, substance use and kummerspeck) is being borne by individual nurses and the people who love them. Clinical supervision allows another way – through guided reflective practice many of these costs can be prevented.

I don’t see why looking after a nurse’s practice and emotional self through regular confidential support with a trusted colleague would be any less important than looking after a nurse’s back. Australian health facilities all have tools, time and training devoted to safe lifting, it is time to provide tools, time and training devoted to safe thinking.

Clinical supervision is available to mental health nurses, but not nurses in general hospital wards. In his epic novel Catch-22, Joseph Heller wrote:

People knew a lot more about dying inside the hospital, and made a much neater, more orderly job of it. They couldn’t dominate Death inside the hospital, but they certainly made her behave. They had taught her manners. They couldn’t keep death out, but while she was in she had to act like a lady. People gave up the ghost with delicacy and taste inside the hospital.

It is the nurses that make death and illness more neat, orderly and ladylike.

It is the nurses who paper-over the holes punched in the walls.

It is the nurses who stay on the ward to make sure that care keeps going in.

The nurses should be provided with an avenue to let crap out.

Guided reflective practice (aka clinical supervision) should be available for all nurses and midwives.

Closing Remarks

I would like to leave the story there because I have waffled-on for a long time already. However, it is necessary to address two tricky subjects raised in this blog post: [1] mental health and violence, and [2] my use of “fire extinguisher guy” when referring to a hospital patient.

Mental Health and Violence

Let’s get the facts straight:

the overwhelming majority of people who experience mental health problems are not violent: never have been and never will be

most violence is not perpetrated by people with a mental health problem

people who experience mental health problems are more likely to be victims of violence than perpetrators

I started specialist education in mental health nursing in 1993 and have spent most (not all) of my career working in clinical mental health nurse positions since then. I have never been physically assaulted by a person experiencing mental health problems. Never. However, earlier in the week there was a newspaper article reporting that “half of the nurses working on hospital psychiatric wards are themselves suffering from mental illnesses such as post-traumatic stress disorder, depression and anxiety.” I know that I have been more fortunate than some of my colleagues.

There are lots of myths and misunderstandings about mental health and violence. Please scroll to the bottom of the post for evidence-based resources and references.

Explanatory Note re the use of “Fire Extinguisher Guy”*

Using the term “Fire Extinguisher Guy” protects confidentiality and is, obviously, an irreverent, playful way to refer to a person. I don’t think this is wise for somebody creating a professional social media portfolio – somebody might think I’m being disrespectful.

Yet, here i am doing it anyway. Why?

Irreverence, humour and playfulness can be useful defence mechanisms: used correctly they can trivialise the other/traumatic events and empower the self. During the event I did what I could (very little) to assist this man to regain control and to keep himself and others safe from physical harm. It would not be useful to dwell on how powerless and vulnerable we all were at that time. I spent many hours talking to the man both before and after the event and treated him with kindness, respect and dignity.

Lately I’ve been thinking a lot about how we nurture those who nurture: nurses and midwives especially. It’s a subject that has popped-up in a couple of journal articles, on social media (including my recent blog), and in conversations at work.

Before we think about nurturing nurses, let’s think about miners.

Believe it or not, the mining industry with its big burly blokey image has some valuable lessons in nurturing for us namby-pamby health industry types.

Back about 100 years ago Welsh coal miners said to their bosses, “We work hard in your mines all day. We get sweaty and covered head to toe with coal dust from your coal mines. Then we go home and use our time, our bath, our laundry to get cleaned up. It’s a mess of your making, shouldn’t the daily cleanup be your expense?”

Then, as now, the mining industry bosses threw their collective hands in the air and said, “No! We can’t afford to do that! Your excessive demands will send us broke!”

So the miners went on strike.

And stayed on strike until, eventually, the mining companies installed pit head baths so miners could get cleaned-up and changed in the boss’s time, using the boss’s resources. It’s called “Pit Head Time”: it’s enshrined in award conditions for miners and pit head baths are just part of the infrastructure of mines.

Todd and Brandt clocking-off.

Remember the Beaconsfield miners emerging clean and shiny after a fortnight underground? They clocked-off AFTER getting cleaned and changed. The infrastructure is in place – somewhere between the working part of the mine and the clocking-on/off area is a shower and change room – the pit head baths. The miners clock-off by moving their tag from the red “underground” section of the board to the “safe” green area of the board. That’s how pit head time works – you clock-off after you’ve cleaned-up.

Nurses get covered head to toe in the emotional experiences of people who are, very often, having the worst, most traumatic, day(s) in their life.

Shouldn’t nurses get cleaned-up on the boss’s time too?

Clinical Supervision

Clinical Supervision is the name given to the process of cleaning-up after doing emotional labour.

Clinical Supervision is a slightly clumsy name for it, because the word “supervision” implies scrutiny. Nurses are a bit thingy about scrutiny. Nursing was born in the church and raised by the military – it has shameful history of bombastic, bullying, bellowing scrutiny. Nursing and feminism (ie: the gender equality movement) have fought hard to overcome the worst of some very bad power imbalances. That’s why it’s understandable that some nurses are cautious about volunteering for something called “Clinical Supervision” without understanding it fully.

Clinical Supervision does go by some nom de plumes: “Supported Reflective Practice” and “Guided Reflective Practice” being the most common alternatives I’ve come across. Whatever the nomenclature, they each generally attend to the same task – assisting and supporting the clinician to reflect on their work, with the intent of keeping them and their practice safe.

Brigid Proctor is considered one of the rock stars of Clinical Supervision, mostly because she had the capacity to simply articulate the primary functions of Clinical Supervision.

The Formative Function of Clinical Supervision (learning) attends to developing skills, abilities and understandings through reflecting on clinical practice. We don’t know what we don’t know; sometimes it is only through reflecting on our work with a trusted colleague that we get a glimpse of some of our blind spots.

The Normative Function of Clinical Supervision (accountability) is concerned with maintaining the effectiveness and safety of the clinician. Sometimes we need a trusted colleague to prompt us to revisit clinical practice guidelines, policies, procedures and legislation as a way to make sure we’re working within expected norms in everyday practice.

The Restorative Function of Clinical Supervision (support) addresses the inevitable emotional response to the privilege, the frustrations, the joys, and the stresses of working in a caring, nurturing role. Sometimes it is only through discussing our work with a trusted colleague that we recognise the emotional effects of our work, and learn how to manage our reflex responses.

It is the restorative function of clinical supervision that I value the most. By (metaphorically) cleaning-up the dust and grime I get covered in doing emotional labour, I feel that I am being nurtured, sustained. By being nurtured in the workplace not only do I avoid spending my entire wage at Dan Murphy’s bottle shop as a maladaptive coping strategy, but it also equips me with the capacity to nurture others.

In some workplaces (mine included) there have been attempts made to make Clinical Supervision part of the infrastructure, just like the showers and change rooms the Beaconsfield miners used. If you’re interested in an example of what the infrastructure for assisting clean-up after emotional labour looks like, take a look at the Queensland Health (2009) Clinical Supervision Guidelines for Mental Health Services [PDF].

I know that many of my Nurse and Midwife colleagues don’t have this infrastructure available to them, and I can’t understand why. If it’s good enough for miners to have pit head baths and pit head time, surely it’s good enough for Nurses and Midwives to have Clinical Supervision.